Approved!!!!! I think......

blossom · August 25, 2004

I got a letter from my insurance yesterday, but I don't really understand it. Can someone tell me what this really means? Here is the letter:

We have completed our review of your request for coverage of Bariatric Surgery under the (company name) benefit plan.

Based on the information reviewed, we are please to inform you that coverage is available. All covered charges are subject to screening for allowable charges. The final allowable charge will be determined when the bill is submitted and will be based on the actual service(s) provided.

Please note this letter does not guarantee payment. Benefit payment is based on the provisions of the (company name) benefit plan and is subject to the guidelines, plan design, and policies effective at the time of service.

If you have any questions blah, blah, blah....

I don't get it! How am I supposed to know how much they will pay and how much I will be out of pocket? This will be critical info for me since DH and I are right in the middle of seeking a loan for buying some property. We are having to be very careful with money at the moment.:think

DeLarla · August 25, 2004

Blossom, you should call your insurance company. The letter says they'll cover "bariatric surgery" but it doesn't specifically say they'll cover the LapBand. My insurance covers bariatric surgery, but only a gastric bypass. Better to call them to make sure the Band is covered, and if it is, they should be able to tell you the maximum they'll cover. Then call your doctor and find out how much the surgery is. Make sure to ask you doctor for the "total" costs since the doctor has a separate fee, the hospital has a separate fee, and the anesthesiologist has a separate fee. My doctor in Mexico charged a flat rate (he paid the hospital & anethesiologist out of the money I gave him) but other people had to pay the doctor and hospital separately. I required a second surgery to remove my port, which cost me about a grand. I'll need a third surgery to replace my port, which will cost me about $2 grand, and I'm a self-pay, and I still owe my doc $800 for the 2nd surgery, which means I certainly don't have the money for the third surgery. So if money is a big issue, make sure to ask your insurance if they cover aftercare, and don't forget to ask specifically about the LapBand. If they say YES, then rock on girl and go get banded!

Alexandra · August 25, 2004

Blossom, most of that letter is standard disclaimer language. Nothing is ever promised before they see the actual claim, because they have to let you know they'll be watching out for inappropriate charges.

That said, this is a HUGE step in the right direction. The next step is for your surgeon to put in a request for precertification, and that's when he'll tell them specifically what procedure you will be having. It's at that point you'll know whether they will agree to cover the band as opposed to some other bariatric surgery.

The question of how much they will cover can be answered by looking at your policy. Every policy has terms that are specific to your plan--do you have an HMO or POS? Is your doctor in-network? If so, do you have a hospital copay or are hospital procedures covered at 100%? These questions are answerable no matter what procedure you're contemplating. Banding surgery, if it's a covered treatment, will be covered as any other surgery would be covered under your plan.

I don't agree that you should immediately ask your doctor for the various costs involved. If you have an HMO or POS plan AND you are staying in the network, you shouldn't have to pay anything more than your predetermined share of the costs. (If you have a different type of plan where you are paying a percentage, then of course do the financial investigation necessary.)

I have an HMO and once I got them to agree to cover the band (which was a fight indeed), my total cost was my $20 copay for outpatient surgery. I've had the same copay for each of my fills and office visits since. So it all depends on what kind of plan you have and what the terms are. This letter is not intended to clue you in on those issues--check your plan documents for those details.

blossom · August 25, 2004

Thanks Lisa and Alex!

I found my on-line policy and this is what my POS policy says: Weight reduction: Excluded are hospitalization, surgery, treatment, and medications for weight reduction other than for approved treatment of morbid obesity. If you are covered by the Point-of-Service Medical Plan, contact UnitedHealthcare to determine if treatment is covered.

So, does that mean that it is pointless for my dr. to request precertification? Or does the letter I received override that exclusion?

I'm sorry for all the questions, I'm just so confused!

Alexandra · August 25, 2004

Blossom, the key words there are "other than for approved treatment for morbid obesity." You ARE getting that approved treatment, so it all will be covered. As long as you have that all-important diagnosis of M.O., you're in like Flynn. And I know that United Healthcare is band-friendly. You're good!

DeLarla · August 25, 2004

I'm not sure about all the insurance language so I'm just sharing information I've come across. I do know that a lot of insurance companies that cover the band will require you to first exhaust other means of weight loss. Some require you to document a diet for 6 months or so. If your HMO covers your surgery, you don't have to worry about all the separate charges. But if you have a PPO or end up self-paying, I just wanted to warn you of hidden charges. When my doctor said he wouldn't charge me to remove my port, he accidentally left out the part that I'd have to pay the hospital and anesthesiologist around $2 grand.

New Hope · August 25, 2004

Blossom, here's my experience w/United POS. Oct., 2003, I was denied. Appealed. May, 2004, had Lapband. The day of preregistration, the hospital called ins. to determine my cost. I had to pay $250 co-pay (total expenses). But I also had to pay $500 to the assistant surgeon. (That is supposed to be filed w/ins. co. But I honestly don't expect to see it again. Haven't heard anything about it.) I ended up having 4 surgeries done during that one procedure -- removal of gallbladder, removal of numerous abdominal adhesions (caused from previous open-method kidney removal), removal of unknown benign tumor on esophagus, and installation of band). (This is certainly not the norm for a Lapband patient!) I ended up having to stay an extra day and on i.v. antibiotics an extra day because of the "extras" done. I was very thankful to know that $250 had me covered. I bet that assist. surgeon wished he'd gotten more $$ from me! My total bill was over $48,000.

Be sure that your insurance definitely covers the Lapband procedure (not just gastric bypass - RNY). Be sure the surgeon and hospital you are using is in the insurance network. Check if your aftercare (fills) will be covered by ins. plan. Be sure the dr. has any preop tests, surgery, hospitalization preauthorized. Hospitals and ins. co. negotiate the amt. to be paid. Ins. co. don't pay the full amt. a self-pay would have to.

Yea, I'm so happy! You're moving in the right direction! Now, don't get impatient if it still takes some time to see any specialists, pretests, etc. done.

Start drinking that Water and walking!

blossom · August 25, 2004

Thanks, ya'll!!! I called the dr office to make sure they got their copy of the letter. I was told that they are now requesting the precertification, which will take about 3 weeks. They even wanted to go ahead and set a date!! Ordinarily, I would go ahead and set it, but we just happened to have recently found THE perfect property to build our dream home on, so I am afraid to do ANYTHING until we close. If all goes well, closing will be around the end of October.

Anyway, thanks so much for helping me understand this!

Maurice · August 25, 2004

Your surgeon's office should provide the answers. They're in the business of communicating with the insurance companies.

blossom · August 25, 2004

Marie, did you have to go through the same approval process for each of your surgeries? I am thinking of asking for a tubal ligation at the same time as my LB surgery. My policy says it is covered, so I don't know if I have to go through all the same hoops to get it done.

New Hope · August 25, 2004

No, we already knew the gallbladder was bad. So that was approved w/the initial banding. But the tumor and the adhesions weren't known until he did the actual surgery. I would think if you're wanting the tubalization, that would need to be preauthorized -- since that's a "planned" procedure. Do you know if your banding surgeon does that type of procedure? I was very fortunate in having a laproscopic specialist surgeon, so he knew his stuff. I'm so thankful that he literally tunnelled all across my abdomen to fix all four things - laproscopically! I was sent home w/ an abdominal drain (for a week), but again, that's not the normal situation. If you can get both approved and done at the same time - go for it! It sure beat having to go through 4 surgeries!

blossom · August 26, 2004

Thanks, Marie! My surgeon is also a laporoscopic specialist, so I am betting he's done plenty of tubals. I will call and find out!

New Hope · August 26, 2004

Blossom, my insurance hospital co-pay is $250 for each hospital stay. If I'd had to do each of these separately, that's $1,000. Plus if I would have used this surgeon, I'd had to pay the assist. surgeon $500 each time ($2,000). I didn't even know I had the esophagus tumor. But my wonderful surgeon found it, removed it, and put dissolvable stitches on the esoph. I was so shocked about that little find, that I didn't truly appreciate my band for a few days. He said this tumor would not have shown up on any tests, would have certainly become cancerous, and started causing breathing problems. Wow, one more reason to love my band!